How to Write Care Notes
Care Notes Tell Family how you are helping and giving value
Notes should be an opportunity to share with the family everything happening for their loved ones - it’s also important to show your services and everything you do!
1. What companion activities were done today
- games, conversation topics, what they enjoy in life right now, celebrations
“We played scrabble today and she won twice” “she was sharing how she really enjoys when the grandkids visit”
2. What care activities were done today
- Meals prepared, showered/bath taken, walk, errands, outdoor activities, exercises
“We made spaghetti and meatballs - I froze a few to reheat over the weekend” “she did/did not want to take a shower today” “I was able to change her bed sheets and do the laundry and wipe over the kitchen benches”
3. Over health observation
- has their mental /cognitive health improved, stayed the same, deteriorated.
- Did you notice anything eg “J struggled to walk today longer than a few minutes” “J was trying to make phone calls to pay bills and I had to discourage her"
Elderly Care Services
How to write notes for insurance claims.
A insurance client must have at least 3 ADLS with stand by or hands on assistance each visit. One day missing means they get declined.
Save 15mins at the end of your shift and let client know you are doing care notes.
Consider the ADLS are:
- Bathing/showering
- Toileting
- Eating
- Transferring (moving from one area to another)
- Incontinence
- Dressing
Consider was support provided hands on or stand by:
Hands on - physically touched persons body or tool to help
Stand by - prepared or stood by and watched to prevent potential injury.
Now notes should look like this. Feel free to copy these individual relevant statements into your notes.
I provided hands on assistance with Jane’s bathing and showering.
I provided stand by assistance when she went to the toilet.
I provided Hand on assistance to transfer her and help her out of her chair and move her to the dining area.